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News & Notes

Mark Your Calendars: Pelosi Expects Drug Pricing Bill in September

A top aide to Speaker Nancy Pelosi (D-Calif.) said House Democrats will unveil their long-awaited bill to lower drug prices in September. Wendell Primus, Pelosi’s top health care adviser, in July said House leadership was almost ready to release the proposal but opted to hold off so that drug companies could not attack it during the August recess, according to a news report published by Kaiser Health News. To read more Kaiser Health News, visit https://khn.org/ or click here: https://tinyurl.com/y4ocquwp

Senate Health Committee Continues to Work on Lower Healthcare Costs

Senate health committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.) in late July released the following statement on the bipartisan Lower Health Care Costs Act of 2019: “The Senate does not have time before the August recess to consider the bipartisan Lower Health Care Costs Act, which the Senate’s health committee approved 20-3 on June 26, and includes proposals from 74 of our colleagues—35 Republican and 39 Democratic Senators.” To read more from the Senate Health, Education, Labor and Pensions Committee, visit its website at https://www.help.senate.gov.

For more health care collections news, visit ACA’s Health Care Collections page at www.acainternational.org/pulse.

 

 

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JAMA Study Finds 36% of Virginia Hospitals Garnishing Wages Over Unpaid Bills

Not every hospital sues over unpaid bills, but a few sue a lot, according to an article published by NPR.  While admitting there “are no good national data on the practice,” NPR writer Selena Simmons-Duffin notes journalists have reported on hospitals suing patients all over the United States– from North Carolina to Nebraska to a hospital in Missouri that sued 6,000 patients over a four-year period.

Simmons-Duffin’s article titled, “When Hospitals Sue for Unpaid Bills, It Can be ‘Ruinous’ for Patients,” focuses on a study published by JAMA: The Journal ofAmerican Medical Association that looks into 2017 Virginia court records on completed warrant-in-debt lawsuits filed by hospitals resulting in garnishment of a patient’s wages.

The JAMA study, led by Martin A. Makary, MD, MPH, of Johns Hopkins University in Baltimore, identified 20,054 warrant-in-debt lawsuits and 9,232 garnishment cases in 2017. Garnishing was conducted by 48 of 135 Virginia hospitals (36%), of which 71% were nonprofit and 75% urban, compared with 53% nonprofit and 91% urban among hospitals that did not garnish, according to the study titled, “Prevalence and Characteristics of Virginia Hospitals Suing Patients and Garnishing Wages for Unpaid Medical Bills.”

“Thirty-six percent of Virginia hospitals garnished wages in 2017, with a small number of hospitals accounting for most cases,” the Johns Hopkins researcher said. “Some characteristics suggest that hospitals with greater financial need (nonprofit, lower annual gross revenue) may be pursuing debt collection to the final stage of garnishment.”

The most common employers of those having wages garnished were Walmart, Wells Fargo, Amazon and Lowes, accounting for 8% of patients whose wages were garnished, the study said. This point was central to Simmons-Duffin’s article, which focused heavily on Mary Washington Hospital, a Fredericksburg, Va.-based hospital that’s part of the Mary Washington Healthcare network. (The JAMA study found that five hospitals accounted for more than half of the lawsuits, with Mary Washington suing the most.)

In response to NPR’s report, Mary Washington officials noted that lawsuits are rare (less than 1% of their patients go to litigation). Lisa Henry, communications director for the health care system, said: “It’s important to us, as a small community, and a safety net hospital, that we’re doing everything we can for our patients to avoid aggressive collections.”

Mary Washington has a months-long process for trying to reach patients before it takes legal action. “By phone, by mail, by email — any access point we’re given from them when they register.  “Unfortunately, if we don’t hear back from folks or they don’t make a payment we’re assuming that they’re not prepared to pay their bill, so we do issue papers to the court.

Because court records are public, Mary Washington officials noted that they are subject to more scrutiny than hospitals that use collection agencies.  “We’re really unclear as to why Mary Washington Healthcare in particular has become the face of this,” Henry says. “I don’t think we’re alone — all hospitals are struggling with, ‘How do we collect appropriately from our patients to stay open as a safety net hospital?’”

Meanwhile, Makary, the corresponding author on the JAMA study who is also a surgeon at Johns Hopkins, was so “outraged” over Mary Washington’s efforts to recoup unpaid debt that he formed an advocacy campaign to encourage the hospital to “stop suing low-income patients for bills that they simply can’t afford,” the NPR article stated.

In defense of Mary Washington, Henry noted that most patients who are eligible sign up for financial assistance and payment plans, the article said. According to its website, [Mary Washington Healthcare’s] “not-for-profit status drives us to be the kind of organization that provides care to those in need, regardless of their ability to pay. We provide significant financial assistance.”

 

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Consumerism in Healthcare: What ASC’s Need to Know

 

Consumerism in Healthcare: What ASC’s Need to Know

The ASC market is expected to grow at a 4 percent compound annual growth rate (CAGR) from 2017 to 2027, according to Future Market Insights, with multispecialty ASC’s expected to dominate reaching $76.8 billion over the next decade. As the industry moves toward value-based care, patients are increasingly interested in lower priced settings such as outpatient surgery and ASC’s which are disrupting traditional care models. 

However, ASC’s are in a delicate place in terms of meeting patient’s ever-increasing and rapidly changing expectations. Consumerism in healthcare has been an ongoing complex study which is a challenge even for ASC’s.

ASC’s have a lot to learn from customer-centric business models implemented within other industries like retail and tech. Here are just a few of the things that ASC’s need to learn in order to adapt to the increasing consumerism trend: 

The four pillars of consumerism: access, experience, pricing, and infrastructure

Kaufman Hall’s 2019 Healthcare Consumerism Index reveals the challenges that legacy healthcare providers face in adapting to the ever-rising bar of consumer needs and expectations.

Here are some key takeaways from their report:

  • Only 8% of hospitals and health systems demonstrate strong consumer-centric performance
  • A staggering 68% of organizations either have not begun (29%), or are in the very early stages of their consumerism efforts (39%)

For ASC’s and the healthcare industry as a whole to catch-up in an online, convenience-obsessed, and increasingly consumer-focused world, they would need to excel in the four pillars of consumerism.


Access: Today’s consumers increasingly demand quick and easy access to any and all services through a variety of access points—whether physical or virtual—with digital tools to add convenience. 

  • More than half of respondents offer urgent or ambulatory care centers, but only a third offer widespread, basic online scheduling for existing patients.

Experience: Enhancing the consumer experience has a lot to do with patient communication.  Some strategies include: automated appointment reminders, centralized call routing, electronic messaging between patients and providers, consumer-friendly billing and payment options. 

  • Few offer real-time scheduling and communications necessary to keep pace with today’s digitally connected consumers.

Pricing: A recent Kaufman Hall survey of how US consumers find and select providers and services found that more than a third research costs in selecting where to go for comparable services. As expectations rise and federal and state laws move toward requiring greater transparency, healthcare providers must implement effective pricing strategies and tools to communicate price estimates to consumers conveniently and accurately.

  • Only few of healthcare providers offer true price transparency.

Infrastructure: Overall efforts to build an infrastructure of consumer insights and analytics continue to be sub-optimal relative to its critical importance for competing effectively in the marketplace

  • More than half of hospitals and health systems have developed consumer-centric missions and strategies, but a majority have not yet built infrastructures needed to support such objectives.

Patients are taking an increasingly active role in their healthcare

The rise in healthcare consumerism is driven by a lot of factors, one of which is patients having greater financial responsibility (higher co-pay, deductibles, and overall costs). With such high costs, patients tend to “shop” for surgical options. 

Patients’ expectations are also changing, driven by their experiences from other industries like airlines and retail. Patients demand improved services and enhanced experiences when engaging with providers and health systems. 

As patients are faced with increased treatment choices, care options, and cost concerns, they are now becoming highly active in their healthcare choices.

Patients are increasingly prepared to interact as consumers rather than as passive patients. As consumers, patients want to be in control of the services that they would want to afford. They want to be involved and informed of every step that will be made throughout their healthcare experience.

ASC’s have long led the way in cost-effective and quality care, serving as role models for other providers trying to determine how best to navigate today's evolving landscape that rewards quality over quantity. The number of procedures performed in ASC’s has continually been on the rise, with surgery centers now performing more than 20 million surgeries annually. ASC’s still have a long way to go to be on par with other industries in meeting, or exceeding, a patient’s expectations. Now is the time to ensure that your ASC is on the right track and not lagging in the consumerism trend. 

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Senate Health Committee Votes to Reduce Health Care Costs


Before heading off for the Fourth of July holiday, the Senate Health, Education, Labor and Pensions Committee approved legislation that ends surprise billing, creates more transparency and increases competition to reduce prescription drug costs. The bill, known as the “Lower Health Care Costs Act” was approved in a 20-3 vote.

“Altogether, this legislation will help to lower the cost of health care, which has become a tax on family Budgets and on businesses, on federal and state governments,” said Committee Chairman Lamar Alexander (R-Tenn.). 

“A recent Gallup poll found that the cost of health care was the biggest financial problem facing American families. And last July, this committee heard from Dr. Brent James, from the National Academies, who testified that up to half of what the American people spend on health care may be unnecessary.”

Additional information may be viewed on the Committee’s website accessible here: www.help.senate.gov

 

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Unforeseen Out-of-Network Charges Cause Concern Amongst Consumers 


About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published in June. On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims.  

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill. “Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017,” the authors wrote. 

The researchers got their data by analyzing large-employer claims from IBM’s MarketScan Research Databases, which include claims for almost 19 million individuals. Surprise medical bills are top of mind for American patients, with 38% reporting they were “very worried” about unexpected medical bills. Surprise bills don’t just come from the emergency room.  

Often, patients will pick an in-network facility and see a provider who works there but isn’t employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices. “It’s kind of a built-in problem,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don’t know whether they are being treated by an out-of-network doctor while in a hospital. 

“By definition, there are these circumstances where they cannot choose their provider, whether it’s an emergency or it’s [a doctor] who gets brought in and they don’t even meet them face-to-face.” The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don’t apply to most large-employer plans because the federal government regulates them.  

“New York and California have very high rates of surprise bills even though they have some of the strongest state statutes,” Pollitz said. “These data show why federal legislation would matter.” Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study. Legislative solutions are being discussed in the White House and Congress.  

 

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What Keeps You Up at Night?

The cost of healthcare in the United States is a significant source of apprehension and fear for millions of Americans, according to a new national survey conducted by West Health and Gallup. With over $3.5 trillion—nearly one-fifth of the nation’s gross domestic product — spent in 2017 alone, the national poll indicates this financial burden causes a multitude of worries and anxieties for a large segment of American adults.

These findings were published in a report titled “The U.S. Healthcare Cost Crisis,” based on a nationally representative survey of more than 3,500 American adults on the impact of the high cost of healthcare on personal finances, individual healthcare choices and the level of satisfaction with the U.S. healthcare system.

Relative to the quality of the care they receive, the study revealed that Americans overwhelmingly agree they pay too much, receive too little, and have little confidence that elected officials can solve the problem.  Americans in large numbers are borrowing money, skipping treatments and cutting back on household expenses because of high costs, and a large percentage fear a major health event could bankrupt them. 

More than three-quarters of Americans are also concerned that high healthcare costs could cause significant and lasting damage to the U.S. economy.  Despite the financial burden and fears caused by high healthcare costs, partisan filters lead to divergent views of the healthcare system at large: By a wide margin, more Republicans than Democrats consider the quality of care in the U.S. to be the best or among the best in the world — all while the U.S. significantly outspends other advanced economies on healthcare with dismal outcomes on basic health indicators such as infant mortality and heart attack mortality.

Republicans and Democrats are about as likely to resort to drastic measures, from deferring care to cutting back on other expenses including groceries, clothing, and gas and electricity. And many do not see the situation improving.  In fact, most believe costs will only increase. When given the choice between a freeze in healthcare costs for the next five years or a 10% increase in household income, 61% of Americans report that their preference is a freeze in costs.  Other key survey findings include:

77% of Americans are concerned rising costs will significantly damage the U.S. economy.

76% expect their costs for healthcare will increase even further in the next two years.

15 million Americans have deferred purchasing prescription drugs in the past year due to cost.

Nearly 3 million borrowed $10,000 or more to pay for healthcare in the past year.

Only about one-third report that doctors discuss costs with them in advance of procedures, tests or treatment plans, or for medicine required to treat their conditions.

The New York Times published an article titled, “Americans Borrowed $88 Billion to Pay for Health Care Last Year, Survey Finds,” that provides an in-depth analysis of the survey. In the piece, reporter Karen Zraick notes that West Health and Gallup will conduct similar studies going forward.

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HHS Payment Model Designed to Meet Beneficiaries’ Emergency Needs

Supporting ambulance triage options aims to allow beneficiaries to receive care at the right time and place.  Earlier this year, the U.S. Department of Health and Human Services (HHS), Center for Medicare and Medicaid Innovation (Innovation Center), which tests innovative payment and service delivery models to lower costs and improve the quality of care, announced a new payment model for emergency ambulance services.   It aims to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs, a press statement released by HHS said.

The new model known as the Emergency Triage Treat and Transport (ET3), will make it possible for participating ambulance suppliers and providers to partner with qualified health care practitioners to deliver treatment in place (either on-the-scene or through telehealth) and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics) to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. 

In doing so, the model seeks to engage health care providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 model will have a five-year performance period, with an anticipated start date in early 2020.

The ET3 model encourages high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a 5 percent payment adjustment in later years of the model based on their achievement of key quality measures. The quality measurement strategy will aim to avoid adding more burden to participants, including minimizing any new reporting requirements.

Qualified health care practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered. The model will use a phased approach through multiple application rounds to maximize participation in regions across the country.

To ensure access to model interventions across all individuals in a region, CMS will encourage ET3 model participants to partner with other payers, including state Medicaid agencies.  CMS anticipates releasing a Request for Applications this summer to solicit Medicare-enrolled ambulance suppliers and providers. In Fall 2019, to implement the triage lines for low-acuity 911 calls, CMS anticipates issuing a Notice of Funding.

There is an opportunity for a limited number of two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate. For more information, please visit: https://innovation.cms.gov/initiatives/et3/ and https://bit.ly/2Ii9ZQD.

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How Insurance Coverage Impacts Consumers’ Ability to Pay

How Insurance Coverage Impacts Consumers’ Ability to Pay

New data on health insurance in the U.S. from The Commonwealth Fund reflects quality of coverage and the impact of coverage levels on consumers’ ability to pay medical bills and access care.  

Among the findings in the Biennial Health Insurance Survey, The Commonwealth Fund reports that consumers who are “underinsured,” meaning they carry high health plan deductibles and out-of-pocket medical expenses compared to their income, are more likely to have challenges paying their medical bills or avoid medical care because of the expense.

Twenty-nine percent of insured adults qualified as “underinsured” in 2018, an increase from 23 percent in 2014.  “U.S. working-age adults are significantly more likely to have health insurance since the ACA [Affordable Care Act] became law in 2010. But the improvement in uninsured rates has stalled. 

In addition, more people have health plans that fail to adequately protect them from health care costs, with the fastest deterioration in cost protection occurring in employer coverage,” said Sara Collins, lead author of the study and The Commonwealth Fund vice president for health care coverage and access, in a news release.

The survey offers a big-picture look at consumers’ health insurance, including the quality of their coverage, in 2018.

Key findings in the survey include:

Twenty-eight percent of U.S. adults who have health insurance through their employer were underinsured in 2018, an increase from 20 percent in 2014.

Consumers who purchased plans on their own through the individual market or the marketplaces were the most likely to be underinsured, with 42 percent reporting a lack of adequate coverage in 2018.

Forty-one percent of underinsured adults reported they held off on care they needed because of the expense, compared to 23 percent of consumers with “adequate insurance coverage.”

And, 47 percent of underinsured adults said they had medical bill and debt problems, compared to 25 percent of consumers who are not underinsured reporting these challenges.

More information: https://bit.ly/2GAEZsT

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3 Tips for Working with RCM Partners to Handle Self-Pay Patients

Patient balances present one of the most significant challenges in healthcare especially for surgery centers. With ever-rising healthcare costs, ambulatory surgery centers (ASC’s) see an increase in the number of patients that have high deductible health insurance plans. Patient obligations have increased 29.4 percent since 2015, and many are finding it difficult to pay off their medical bills and large out-of-pocket costs.

ASC’s invest significant resources and time to settle overdue payables from patients who are unable to manage paying off their medical bills. Many surgery centers find themselves reaching out to patients, sending letters, emails, and calls in an effort to collect from self-pay patients. 

However, collecting from patients is not naturally the expertise of a healthcare facility, so surgery centers often get the help of an RCM (revenue cycle management) partner or collections vendor.

How can your ASC work more effectively with its RCM partners to handle self-pay collections? What do you need to look for in selecting a third-party collections partner? Here are 3 tips to consider:

1. Implement Digital Payment Transmissions 

Interestingly, the increase of high-deductible plans has also coincided with the trend of healthcare consumerism. Patients now expect that they can pay their bills and manage their accounts online from their mobile phones or desktops. 

Surgery centers can work with their RCM partners to step up their game and make it easy for patients to register by tablet and pay electronically and get payment in advance for elective procedures. 

With self-pay patients, it is important to choose partners that are able to offer automatic enrollment in payment plans and financial counseling to avoid revenue leakage. 

2. Leverage Automation Technology

By its nature, self-pay accounts are risky. The cost to collect could reach up to three times higher than on commercial insurance accounts. The longer a self-pay balance goes unpaid, the harder and costlier it is to collect it.

This is why automation is becoming the new standard in revenue cycle management. Choose partners that can use automation to step up collection efforts of past due medical debts, decrease human error, maximize productivity, reduce costs, and streamline processes.

Here are four essential areas that needs vendor automation especially for self-pay accounts:

Daily accounts submission

Daily payment and adjustment account reconciliation

Vendor collections automatically directed to existing merchant services

Automatic invoices that are gross remit and auto-paid 

3. Focus on Personalization: Patient-Centric Financial Experiences  

With the help of your RCM partner and the use of technology, your facility can gain visibility into patient payment behavior and identify trends, bottlenecks, and needs. A one-size-fits-all approach doesn’t work with self-pay accounts. Hence the need for better personalization.

Here are some areas to focus on to create patient-centric financial experiences:

Improve medical bill (eliminate areas of confusion) 

Using price transparency tools

Patient education strategies

Flexible payment methods

Patient financial advocates

Having trained and patient-friendly staff (front-end and collections)

Better patient communications

The key to better personalization is using technology and training your staff. Work with your RCM partner to have full visibility into where all payments are coming from and have daily activity reports on all types of payments received, categorized according to account number, source of payment, etc. By having a 360-degree view of patient payment behavior, your ASC can create strategies that would personalize self-pay collections and achieve higher success rates.

 

 

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Patients Prefer Payment Plans for Medical Bills



As out-of-pocket health care costs continue to increase for consumers, more prefer payment plans to manage their medical bills, according to the “Changing Landscape of Health Care Payment Plans” report, produced by
PYMNTS in collaboration with Flywire. Data on the report is based on a survey of 2,837 patients who checked
into a hospital or emergency room in the previous year.

Key findings include:

57 percent of respondents would prefer a payment plan offered before service or at the time of service with their health care provider.

35.5 percent would prefer a payment plan offered at the time they receive their first bill.

Just 6.9 percent choose a phone call from their provider to ask for a plan.

There is a direct relationship between a patient’s increased out-of-pocket payments and the chance they will sign up for a payment plan:

38.9 percent of respondents used payment plans to manage out-of-pocket expenses ranging from $50 to $250.

When costs topped $1,000, 51.4 percent opted for payment plans.  Payment plan fees influence how patients make decisions connected to payment plans, for example:

33.7 percent choose shorter terms to reduce fees.

17 percent pay balances in full to avoid fees.

25 percent say fees have no influence on their decision on how to pay.

“The study offers important insights for hospitals and health systems seeking to optimize their revenue cycle practices and payment plan strategy, as well as to improve payment behavior without jeopardizing the relationship between patient and provider,” John Talaga, executive vice president, Flywire, said in a news release on the study.  More information: https://bit.ly/2CDJMpH

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Why a Patient Friendly Billing and Payment System Matters

 



To boost your bottom line, it may pay to consider patient consumerism when dealing with your patients. Because when a patient schedules a visit for medical care, they’re not simply thinking about the quality of care. They’re thinking about the value they’re getting from the visit, even if they have medical insurance coverage. Here are some of the realities patients and care providers are facing in regards to patient consumerism:

In the past decade, high-deductible health plans have become the norm for millions of Americans, meaning your patients’ out-of-pocket expenses cover the gamut, from $1,350 for individuals to $13,300 for families.  That means even with tools like health savings accounts, patients are more watchful than ever over their health care dollars.

Some of the struggling patients are young: Patients in their late 20s were more likely to have medical debt in collections than older patients, despite the fact they were less likely to use medical services, according to a 2018 study published in Health Affairs. Another surprise: Half the accounts in collections were for less than $600.

Three-quarters of a percent of health care providers saw a rise in patient responsibility for payments in 2015, according to a report in Rev Cycle Intelligence. And health care providers aren’t recovering the full balance from the patient but recouping 50-70 percent of the billable amount.  To work within these new realities, health providers can take proactive steps to make access to medical care more patient-friendly, and one area of focus could be in the realm of billing and collections.

Better front-end procedures: When a patient goes about their daily lives, they have become accustomed to completing many transactions online or with a smartphone app, whether they want to apply for a new job, shop for necessities, order food, get a ride, buy concert tickets, or transfer funds. When a patient wants to see a doctor, patients are still picking up the phone to book appointments and filling out paper forms in the waiting room.

Offering an online scheduling system is a more convenient way for patients to book (and reschedule) appointments. Giving patients the ability to fill out electronic intake forms can reduce data entry errors, speed up the billing process and ensure that your billing department has accurate information about the patient.

Communicate about costs: From a patient’s perspective, medical costs are notoriously difficult to plan for. Health Care providers can help patients prepare by informing them of their payment responsibility upfront. Some providers even supply chargemaster prices, with a strong caveat that the amount could change after their insurer processes the visit.  When patients gain the ability to plan for these expenses, it can reduce stress in patients and build trust.

Smarter collections: The final step in the patient interaction is billing. Accepting online credit card payments makes it easy, convenient and safe for patients to pay their bills. When patients are late with payments, good communication is key to recovery, especially if the phone calls and letters help patients understand their options to catch up on their late bills. Finally, treat past-due patients with respect and compassion. When it comes time to send these accounts to a collection partner, experience and professionalism count.

Health care is a major expense for patients, which is why it’s important for clinics and practices to demonstrate the care just as much for a patient’s financial health as they do their physical health.

Brian Eggert is a business development specialist and writer for IC System. Moreinformation: https://bit.ly/2AZ010l

 

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How to Prevent Revenue Leakage in Your ASC

The healthcare reimbursement landscape has changed dramatically in just a few years. Just five years ago, healthcare providers could get 90% of their revenue from government payers (Medicare and Medicaid) and commercial insurance companies, while the remaining 10% comes from patient payments.

Today, patient payments can make up as much as 33% of provider revenue. Last year, enrollment in high-deductible health plans surged to include nearly half (47 percent) of those privately insured. 

The biggest challenge facing healthcare providers is the change from payer-based (insurance) revenue to consumer-driven reimbursement.

Many providers typically do not receive full reimbursement because patient collections are leaking throughout their revenue cycle. Some do not even detect the source or depth of their revenue loss.

Track Revenue Cycle Leaks 

It pays to know how much revenue you’re truly missing out on, and where they are coming from. Leakage could come from coding errors, manual payment and collection processes, unbilled revenue, and poor denials management.

It is important to conduct thorough audits that can find even fewer common areas where revenue leakage can occur. For example, unbilled insurance can lead to lost revenue for your ASC. To solve this problem, create reports that track unbilled insurance. In the same way, you can also have a report that tracks unbilled patients, including self-pay, promissory notes and patient balances after third-party payor responsibility is met. Insurance/eligibility verification also helps to increase clean claims rates, eliminate costly rework and accelerate reimbursement. Hence, it is good to have reports that show who has been verified.

It’s essential that each procedure performed in the practice becomes a claim in the billing process. If your billing company does not audit and validate the receipt of your interpretation reports, you easily could be losing 10% or more of your revenue, no matter how effectively the rest of your billing process performs.

Stop Patient Leakage

In 2018, a survey of healthcare executives conducted by Sage Growth Partners and Fibroblast revealed that 43% of the respondents report losing 10% or more of their annual revenue due to patient leakage while 23% don’t even know how much they are losing. Patient leakage translates to revenue leakage.

“Patient leakage” is the industry term when primary care physicians refer patients to out-of-system providers (instead of those in their network), resulting in significant business losses. It could also refer to patients seeking out other healthcare groups (out-of-network) for their care. 

Patient leakage also happens when a patient referral that should stay inside a health network ends up leaving for another or a patient that should receive care in the network doesn't follow through on the care.

Why does this affect an ASC’s bottom line? Your facility could lose considerable revenue and control when patients are being referred to other networks or to poorer performing providers within their own network. In a value-based care model, patient leakage can also pose a risk due to patients developing an event that is more acute than it should've been had they received care.

One of the key solutions to prevent patient leakage is better patient engagement and better care coordination. Modern and simple technologies like mobile EHRs, text and email messaging, and patient portals help create a personal connection with patients. In the long run, this builds loyalty and staying power. The provider-patient relationship is always on top of the list on what patients are looking for in their healthcare. 

Here are more suggestions:

Providers should specify referrals in their network. In the survey, client data indicates that 80% of the time, providers neglect to even specify who a patient should see.  

Follow up to see if patients received the care for which they were referred.


By preventing patient leakage and improving reporting and auditing, ASC’s can significantly drop their revenue leakage dramatically and protect their bottom line.

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